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Background CME is a radical resection for colon cancer, but the procedure is technically demanding with significant variation in its practice. A standardised approach to the optimal technique and training is, therefore, desirable to minimise technical hazards and facilitate safe dissemination. The aim is to develop an expert consensus on the optimal technique for Complete Mesocolic Excision (CME) for right-sided and transverse colon cancer to guide safe implementation and training pathways. Methods Guidance was developed following a modified Delphi process to draw consensus from 55 international experts in CME and surgical education representing 18 countries. Domain topics were formulated and subdivided into questions pertinent to different aspects of CME practice. A three-round Delphi voting on 25 statements based on the specific questions and 70% agreement was considered as consensus. Results Twenty-three recommendations for CME procedure were agreed on, describing the technique and optimal training pathway. CME is recommended as the standard of care resection for locally advanced colon cancer. The essential components are central vascular ligation, exposure of the superior mesenteric vein and excision of an intact mesocolon. Key anatomical landmarks to perform a safe CME dissection include identification of the ileocolic pedicle, superior mesenteric vein and root of the mesocolon. A proficiency-based multimodal training curriculum for CME was proposed including a formal proctorship programme. Conclusions Consensus on standardisation of technique and training framework for complete mesocolic excision was agreed upon by a panel of experts to guide current practice and provide a quality control framework for future studies.

Background The splenic flexure is irrigated from two vascular areas, both from the middle colic and the left colic artery. The challenge for the surgeon is to connect these two vascular areas in an oncological safe procedure. Materials and methods The vascular anatomy, manually 3D reconstructed from 32 preoperative high-resolution CT datasets using Osirix MD, Mimics Medical and 3-matic Medical Datasets, were exported as STL-files, video clips, stills and supplemented with 3D printed models. Results Our first major finding was the difference in level between the middle colic and the inferior mesenteric artery origins. We have named this relationship a mesenteric inter-arterial stair. The middle colic artery origin could be found cranial (median 3.38 cm) or caudal (median 0.58 cm) to the inferior mesenteric artery. The lateral distance between the two origins was 2.63 cm (median), and the straight distance 4.23 cm (median). The second finding was the different trajectories and confluence pattern of the inferior mesenteric vein. This vein ended in the superior mesenteric/jejunal vein (21 patients) or in the splenic vein (11 patients). The inferior mesenteric vein confluence could be infrapancreatic (17 patients), infrapancreatic with retropancreatic arch (7 patients) or retropancreatic (8 patients). Lastly, the accessory middle colic artery was present in ten patients presenting another pathway for lymphatic dissemination. Conclusion The IMV trajectory when accessible, is the solution to the mesenteric inter-arterial stair. The surgeon could safely follow the IMV to its confluence. When the IMV trajectory is not accessible, the surgeon could follow the caudal border of the pancreas. Graphical abstract

Purpose Mixed reality (MR) is being evaluated as a visual tool for surgical navigation. Current literature presents unclear results on intraoperative accuracy using the Microsoft HoloLens 1®. This study aims to assess the impact of the surgeon’s sightline in an inside-out marker-based MR navigation system for open surgery. Methods Surgeons at Akershus University Hospital tested this system. A custom-made phantom was used, containing 18 wire target crosses within its inner walls. A CT scan was obtained in order to segment all wire targets into a single 3D-model (hologram). An in-house software application (CTrue), developed for the Microsoft HoloLens 1, uploaded 3D-models and automatically registered the 3D-model with the phantom. Based on the surgeon’s sightline while registering and targeting (free sightline /F/or a strictly perpendicular sightline /P/), 4 scenarios were developed (FF-PF-FP-PP). Target error distance (TED) was obtained in three different working axes-(XYZ). Results Six surgeons (5 males, age 29–62) were enrolled. A total of 864 measurements were collected in 4 scenarios, twice. Scenario PP showed the smallest TED in XYZ-axes mean = 2.98 mm ± SD 1.33; 2.28 mm ± SD 1.45; 2.78 mm ± SD 1.91, respectively. Scenario FF showed the largest TED in XYZ-axes with mean = 10.03 mm ± SD 3.19; 6.36 mm ± SD 3.36; 16.11 mm ± SD 8.91, respectively. Multiple comparison tests, grouped in scenarios and axes, showed that the majority of scenario comparisons had significantly different TED values (p Y-axis always presented the smallest TED regardless of scenario tested. Conclusion A strictly perpendicular working sightline in relation to the 3D-model achieves the best accuracy results. Shortcomings in this technology, as an intraoperative visual cue, can be overcome by sightline correction. Incidentally, this is the preferred working angle for open surgery.

Background: There seems to be a gap in knowledge of the anatomy of mesenteric lymphatics between the superior mesenteric nodes and the intestinal trunk. To our knowledge, these central lymph vessels were not hitherto systematically searched for, described, or morphometrically analyzed. Our aim was to identify those vessels on the routine multidetector computerized tomography angiography (MDCTA), performed prior to right colectomy for cancer, with extended mesenterectomy, central vascular ligation, and D3 lymphadenectomy. Methods: A total of 420 MDCTA datasets were analyzed utilizing manual segmentation and 3D reconstruction, with the aid of image processing software Osirix, Mimics, and 3-matic. The 3D models and masks underwent a detailed topographic and morphometric analysis. Results: Significant vascular-like structures, having neither origin nor termination on the blood vessels, were noted in 18 cases (4.3%) in the D3 volume. The dimensions of visible lymph vessels varied, their mean diameter was 1.81 ± 0.61 mm, and the mean length was 38.07 ± 22.19 mm. In the vast majority of cases, the lymph vessels were situated in front of the superior mesenteric artery (SMA), coursing either longitudinally cranially (13 cases) or transversely/obliquely to the left (5 cases). In all cases but one, the lymph vessel passed at the left-hand side of the middle colic artery. As for the course shape, in seven cases, the lymph vessel appeared highly serpiginous. Conclusions: The regular MDCTA can provide valuable information on mesenteric lymphatics and aid in surgical planning.

Purpose: To determine how individual vascular road-mapping impacts the surgeonsâ?? expectations in difficulty in D3 right colectomy for cancer, and compare these expectations to the results previously published. Aim/summary background data:Literature still lacks data on surgeons expectations using preoperative 3D roadmap of the vascular system. Method: Surgeons filled out a survey asking expectations about operation time, estimated blood loss, amount of lymph nodes harvested and difficulty. The patients were classified into 4 groups and 2 subgroups according to the crossing pattern of the ileocolic artery and the jejunal veins. SPSS was used for statistical analysis. Results: Twelve surgeons were included. Eight of them expected type 2 anatomy to be least time consuming while 11/12 indicated anatomy group 4 to be the most. Five surgeons expected low blood loss in group 2 anatomy patients while 10/12 expected higher blood loss in group 4 anatomy patients. Three anticipated that group 2 would generate the highest lymph node yield and while 2/12 surgeons expected the lowest in anatomy group 4. Eight surgeons perceived group 2 as the least challenging while 10/12 experienced group 4 as the most difficult. Compared to previously published results only group 4b operating time met surgeons expectations. Conclusion: Using a vascular roadmap at surgery evens out surgeons expectations in operation time, blood loss, lymph node harvested and difficulty. Comparing expectations to previously published data shows operating time in one anatomy group as the only factor where these expectations were met.

Background The objectives of this study were to evaluate the relationship between ductal morphometry and ramification patterns in the submandibular gland and pancreas in order to validate their common fractal dimension. Methods X-ray ductography with software-aided morphometry were obtained by injecting barium sulphate in the ducts of post-mortem submandibular gland and pancreas specimens harvested from 42 adult individuals. Results Three cases were excluded from the study because of underlying pathology. There was a significant correlation between the length of the main pancreatic duct (MPD) and the intraglandular portion of the right submandibular duct (SMD) (r = 0.3616; p = 0.028), and left SMD (r = 0.595; p p > 0.05). Both dimensions of the SMD showed a significant right-left correlation (p Conclusions Although the length of intraglandular SMD and MPD correlate, other morphometric ductal features do not, thus suggesting a more complex relationship between the two digestive glands.

Background Superior mesenteric artery plexus (SMAP) injury is reported to cause postoperative intractable diarrhea after pancreatic/colonic surgery with extended lymphadenectomy. This study aims to describe the SMAP microanatomy and extent of injury after right colectomy with extended D3 mesenterectomy for cancer. Methods Three groups (I) anatomical dissection, (II) postmortem histology, and (III) surgical specimen histology were included. Nerve count and area were compared between groups II and III and paravascular sheath thickness between groups I and II. 3D models were generated through 3D histology, nanoCT scanning, and finally through 3D printing. Results A total of 21 specimens were included as follows: Group (I): 5 (3 females, 80–93 years), the SMAP is a complex mesh surrounding the superior mesenteric artery (SMA), branching out, following peripheral arteries and intertwining between them, (II): 7 (5 females, 71–86 years), nerve count: 53 ± 12.42 (38–68), and area: 1.84 ± 0.50 mm2 (1.16–2.29), and (III): 9 (5 females, 55–69 years), nerve count: 31.6 ± 6.74 (range 23–43), and area: 0.889 ± 0.45 mm2 (range 0.479–1.668). SMAP transection injury is 59% of nerve count and 48% of nerve area at middle colic artery origin level. The median values of paravascular sheath thickness decreased caudally from 2.05 to 1.04 mm (anatomical dissection) and from 2.65 to 1.17 mm (postmortem histology). 3D histology models present nerve fibers exclusively within the paravascular sheath, and lymph nodes were observed only outside. NanoCT-derived models reveal oblique nerve fiber trajectories with inclinations between 35° and 55°. Two 3D-printed models of the SMAP were also achieved in a 1:2 scale. Conclusion SMAP surrounds the SMA and branches within the paravascular sheath, while bowel lymph nodes and vessels lie outside. Extent of SMAP injury on histological slides (transection only) was 48% nerve area and 59% nerve count. The 35°–55° inclination range of SMAP nerves possibly imply an even larger injury when plexus excision is performed (lymphadenectomy). Reasons for later improvement of bowel function in these patients can lie in the interarterial nerve fibers between SMA branches.

Background Resection margin status is considered one of the few surgeon-controlled parameters affecting prognosis in pancreatic ductal adenocarcinoma (PDAC). While studies mostly focus on resection margins in pancreatoduodenectomy, little is known about their role in distal pancreatectomy (DP). This study aimed to investigate resection margins in DP for PDAC. Methods Patients who underwent DP for PDAC between October 2004 and February 2020 were included (n = 124). Resection margins and associated parameters were studied in two consecutive time periods during which different pathology examination protocols were used: non-standardized (period 1: 2004–2014) and standardized (period 2: 2015–2020). Microscopic margin involvement (R1) was defined as ≤1 mm clearance. Results Laparoscopic and open resections were performed in 117 (94.4%) and 7 (5.6%) patients, respectively. The R1 rate for the entire cohort was 73.4%, increasing from 60.4% in period 1 to 83.1% in period 2 (p = 0.005). A significantly higher R1 rate was observed for the posterior margin (35.8 vs. 70.4%, p p = 0.045). Pathology examination period, poorly differentiated PDAC, and vascular invasion were associated with R1 in the multivariable model. Extended DP, positive anterior pancreatic surface, lymph node ratio, perineural invasion, and adjuvant chemotherapy, but not R1, were significant prognostic factors for overall survival in the entire cohort. Conclusions Pathology examination is a key determinant of resection margin status following DP for PDAC. A high R1 rate is to be expected when pathology examination is meticulous and standardized. Involvement of the anterior pancreatic surface affects prognosis.

Background: Improvement of lymphadenectomy in right colectomy requires removal of all tissue surrounding the superior mesenteric vessels beneath the pancreatic notch. Shortand long-term bowel motility disorders after D3 extended mesenterectomy with consecutive superior mesenteric plexus transection are studied. Methods: Patients without pre-existing motility disorders undergoing D3 extended mesenterectomy were examined 3 times using the wireless motility capsule: before, at 3 wk, and 6 mo after surgery. Segmental transit times and contractility were analyzed using mixed effect modeling. Correlation between contractility and transit time was assessed by the Pearson correlation coefficient. Results: Fifteen patients (4 men), with median age 62 y, were included. Mean values for the three consecutive examinations are as follows. Gastric transit time increased from 237 to 402 and 403 min, respectively. Small bowel transit time decreased from 246 to 158 (P < 0.01) and 199 (P ¼ 0.03) min, respectively. Colonic transit time decreased from 1742 to 1450 and 1110 (P ¼ 0.02) min, respectively. Gastric contractions per minute (CPM) varied from 1.73 to 1.05 (P ¼ 0.01) and 2.47 (P < 0.01), respectively. Small bowel CPM decreased from 3.43 to 2.68 and 3.34, respectively. Colonic CPM ranged from 1.59 to 1.45 and 1.91 (P ¼ 0.08), respectively. Correlation between small bowel (SB) transit time and CPM was _0.45 (P ¼ 0.09) preoperatively, and _0.03 (P ¼ 0.91) 6 mo postoperatively. Conclusions: Extrinsic SB denervation leads to significantly accelerated SB transit, reduced contractility, and disturbed correlation between transit time and contractility early after denervation. Both number of contractions and transit time in the denervated SB show a clear tendency toward normalization at 6 mo.

Objective To assess the impact of individual patient anatomy on operating time, estimated blood loss (EBL), and lymph node yield in right colectomy with extended D3 mesenterectomy, where surgeons have access to a preoperative 3-D reconstruction of the vascular anatomy of patients before surgery. Aim/summary background data Data on the impact of individual patient vascular anatomy when surgeons have an anatomical road map as a guide at surgery is still missing in the literature. Method Consecutive patients enrolled in an ongoing trial were classified into 4 groups and 2 subgroups using a 3-D vascular anatomy reconstruction derived from the staging CT. Outcome measures are operating time, EBL, vascular events, and D3 volume lymph node yield. SPSS was used for statistical analysis. Results One hundred seventy-six (77 men) patients included. Mean operating time was 200 ± 50 min. Type 4b required significantly longer operating time (mean, 219 ± 59) compared to type 3 (mean, 188 ± 43) (p = 0.004). Vascular events occurred most often in anatomy type 4b (20.0%) and 3 (19.2%). No difference in EBL and lymph node yield was found (p = 0.102 and p = 0.803, respectively). Conclusion The use of a roadmap at surgery seems to even differences in operating time, EBL, and lymph node yield, independent of the complexity of the individual patient's central mesenteric vascular anatomy. The incidents of vascular events requiring hemostasis do not cause differences in EBL between the anatomy groups, suggesting that preoperative awareness of the anatomy is beneficial at surgery.

Introduction To improve oncological outcome in right colon cancer surgery, an extended mesenterectomy (D3) is under evaluation. In this procedure, all tissue anterior and posterior to the superior mesenteric vessels from the middle colic to ileocolic artery origin is removed, causing injury to the superior mesenteric nerve plexus. The aim was to study the effects of this injury on bowel dynamics and quality of life (QoL). Methods Patients undergoing right colectomy with conventional D2- and extended D3-mesenterectomy were asked to record stool number and consistency for 60 d after surgery and complete questionnaires regarding QoL and bowel function (BF) before and after recovery from surgery. We compared early postoperative stool dynamics and long-term QoL in the groups and presented graphs depicting the temporal profile of stool numbers and consistency. Results Thirty-three patients operated with a D3-resection and 12 patients with a D2-resection participated. The results revealed significantly higher stool numbers in the D3-group until day 26, with significantly more loose-watery stools until day 40. The most pronounced difference was found on day 9 (Mean difference in the total number of stools: 2.25 stools/day, p=.004. Mean difference in loose-watery stools/day: 2.81 p

Purpose To determine if “medial to lateral” (ML) dissection with devascularization first is superior to “lateral to medial” (LM) dissection regarding numbers of lymph node micro metastases (MM) and isolated tumor cells (ITC) as well as 5-year disease-free (5YDFS) and 5-year overall survival (5YOS) in stage I/II right-sided colon cancer. Methods Two datasets are used. ML group consists of consecutive stage I/II patients from a prospective trial. LM group is the original dataset from a previous publication. All harvested lymph nodes are examined with monoclonal antibody CAM 5.2 (immunohistochemically). Lymph node harvest and 5YOS/5YDFS were compared between ML/LM groups, stage I/II tumors and MM/ITC presence/absence. Results 117 patients included ML:51, LM:66. MM/ITC positive in ML 37.3% (19/51), LM 31.8% (21/66) p = 0.54. The 5YDFS for patients in ML 70.6% and LM 69.7%, p = 0.99, 5YOS: 74.5% ML and 71.2% LM (p = 0.73). No difference in 5YDFS/5YOS between groups for Stage I/II tumors; however, LM group had an excess of early tumors (16) when compared to ML group, while lymph node harvest was significantly higher in ML group (p p = 0.63, and 75.0%/71.4%, p = 0.72, respectively. Death due to recurrence in MM/ITC positive was significantly higher than MM/ITC negative (p = 0.012). Conclusion Surgical technique does not influence numbers of MM/ITC or 5YDFS/5YOS. Presence of MM/ITC does not affect 5YOS/5YDFS but can be a potential prognostic factor for death due to recurrence. Clinical trial Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic Multi-Detector Computed Tomography (MDCT) Angiography” registered at http://clinicaltrials.gov/ct2/show/NCT01351714 .

Background Distal pancreatectomy is the most common procedure in minimally-invasive pancreatic surgery. Data in the literature suggest that the learning curve flattens after performing up to 30 procedures. However, the exact number remains unclear. Methods The implementation and training with laparoscopic distal pancreatectomy (LDP) in a high-volume center were studied between 1997 and 2020. Perioperative outcomes and factors related to conversion were assessed. The individual experiences of four different surgeons (pioneer and adopters) performing LDP on a regular basis were examined. Results Six hundred forty LDPs were done accounting for 95% of all distal pancreatectomies performed throughout the study period. Conversion was needed in 14 (2.2%) patients due to intraoperative bleeding or tumor adherence to the major vasculature. Overall morbidity and mortality rates were 35 and 0.6%, respectively. Intra- and postoperative outcomes did not change for any of the surgeons within their first 40 cases. Operative time significantly decreased after the first 80 cases for the pioneer surgeon and did not change afterwards although the proportion of ductal adenocarcinoma increased. Tumor size increased after the first 80 cases for the first adopter without affecting the operative time. Conclusions In this nearly unselected cohort, no significant changes in surgical outcomes were observed throughout the first 40 LDPs for different surgeons. The exact number of procedures required to overcome the learning curve is difficult to determine as it seems to depend on patient selection policy and specifics of surgical training at the corresponding center.

Background The impact of the position of the middle colic artery (MCA) bifurcation and the trajectory of the accessory MCA (aMCA) on adequate lymphadenectomy when operating colon cancer have as of yet not been described and/or analysed in the literature. The aim of this study was to determine the MCA bifurcation position to anatomical landmarks and to assess the trajectory of aMCA. Methods The colonic vascular anatomy was manually reconstructed in 3D from high-resolution CT datasets using Osirix MD and 3-matic Medical and analysed. CT datasets were exported as STL files and supplemented with 3D printed models when required. Results Thirty-two datasets were analysed. The MCA bifurcation was left to the superior mesenteric vein (SMV) in 4 (12.1%), in front of SMV in 17 (53.1%) and right to SMV in 11 (34.4%) models. Median distances from the MCA origin to bifurcation were 3.21 (1.18–15.60) cm. A longer MCA bifurcated over or right to SMV, while a shorter bifurcated left to SMV (r = 0.457, p = 0.009). The main MCA direction was towards right in 19 (59.4%) models. When initial directions included left, the bifurcation occurred left to or anterior to SMV in all models. When the initial directions included right, the bifurcation occurred anterior or right to SMV in all models. The aMCA was found in 10 (31.3%) models, following the inferior mesenteric vein (IMV) in 5 near the lower pancreatic border. The IMV confluence was into SMV in 18 (56.3%), splenic vein in 11 (34.4%) and jejunal vein in 3 (9.4%) models. Conclusion Awareness of the wide range of MCA bifurcation positions reported is crucial for the quality of lymphadenectomy performed. The aMCA occurs in 31.3% models and its trajectory is in proximity to the lower pancreatic border in one half of models, indicating that it needs to be considered when operating splenic flexure cancer.

Purpose Adjuvant chemotherapy for colon cancer with lymph node involvement (Stage III) has been the standard of care since the 1990s. Meanwhile, considerable evolvement of surgery combined with dedicated histopathological examinations may have led to stage migration. Furthermore, prognostic factors other than lymph node involvement have proven to affect overall survival. Thus, adjuvant chemotherapy in Stage III colon cancer should be reconsidered. The objective was to compare recurrence rates and survival in stage III colon cancer patients treated with or without adjuvant chemotherapy. Further, to assess the impact of extensive mesenterectomy, lymph node stage and vascular invasion on outcome. Methods Consecutive patients operated for Stage III colon carcinoma between 31 December 2005 and 31 December 2015 were identified in the pathological code register by matching colon (T67) and either adenocarcinoma (M81403) or mucinous adenocarcinoma (M84803), with lymph node (T08) and metastasis of adenocarcinoma (M81406 or M84806). Medical records of all identified patients were reviewed. Results Of 216 identified patients, 69 received no postoperative adjuvant chemotherapy (group NC), 69 insufficient adjuvant chemotherapy (FLV or Conclusion The findings imply that subgroups of Stage III colon cancer patients have good prognosis also without adjuvant chemotherapy. For definite conclusions about necessity of adjuvant chemotherapy, prospective trials are needed.

Background We aim to find the incidence of chylous ascites in patients undergoing D3 extended mesenterectomy and evaluate if a routine fat-reduced diet (FRD) has a prophylactic effect. Methods Data from 138 patients included in a D3 extended mesenterectomy trial were collected prospectively. Surgical drains and biochemical testing of drain fluid were used to find the incidence of chylous ascites among the first 39 patients, and a prophylactic fat-reduced diet was then implemented in the next 99 patients as a prophylactic measure. Results In the first 39 patients, we found that 16 (41.0%) developed chylous ascites. After the fat-reduced diet was implemented, 1 (1.0%) of 99 patients developed chylous ascites. Drain discharge was 150 vs. 80 mL daily, respectively, and a regression analysis shows the average leakage in the group with fat-reduced diet was 105 mL/day less than in the patients with no dietary restrictions (p p = 0.8845), and although there was a tendency to a shorter hospital stay when given a fat-reduced diet (7.3 ± 5.4 vs. 8.9 ± 4.9 days), the difference was not significant (p = 0.19). Conclusions Chylous ascites is a very common postoperative occurrence after right colectomy with extended D3 mesenterectomy and may be prevented using a routine fat-reduced diet.

Background Healthcare systems and general surgeons are being challenged by the current pandemic. The European Association for Endoscopic Surgery (EAES) aimed to evaluate surgeons’ experiences and perspectives, to identify gaps in knowledge, to record shortcomings in resources and to register research priorities. Methods An ad hoc web-based survey of EAES members and affiliates was developed by the EAES Research Committee. The questionnaire consisted of 69 items divided into the following sections: (Ι) demographics, (II) institutional burdens and management strategies, and (III) analysis of resource, knowledge, and evidence gaps. Descriptive statistics were summarized as frequencies, medians, ranges,, and interquartile ranges, as appropriate. Results The survey took place between March 25th and April 16th with a total of 550 surgeons from 79 countries. Eighty-one percent had to postpone elective cases or suspend their practice and 35% assumed roles not related to their primary expertise. One-fourth of respondents reported having encountered abdominal pathologies in COVID-19-positive patients, most frequently acute appendicitis (47% of respondents). The effect of protective measures in surgical or endoscopic procedures on infected patients, the effect of endoscopic surgery on infected patients, and the infectivity of positive patients undergoing laparoscopic surgery were prioritized as knowledge gaps and research priorities. Conclusions Perspectives and priorities of EAES members in the era of the pandemic are hereto summarized. Research evidence is urgently needed to effectively respond to challenges arisen from the pandemic. Electronic supplementary material The online version of this article (10.1007/s00464-020-07835-7) contains supplementary material, which is available to authorized users.

Aim The ileocolic vessels are important landmarks in advanced surgery of the midgut. The aim of the present study is to present variations of ileocolic vessels relevant to complete mesocolic excision with D3 lymphadenectomy of the right colon, within their detailed and precise morphometric framework and deriving from a large and consistent series of operated patients. Methods An ongoing prospective trial 'Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic Multidetector Computed Tomography Angiography' was reviewed. The imaging datasets underwent manual segmentation and 3D reconstruction, and the results were validated at surgery. A total of 356 patients were included in the study. Results A cross-section of the series revealed five cases (1.4%) with variation of ileocolic vessels relevant to complete mesocolic excision or D3 extended mesenterectomy. There were two cases with absence of a true classical ileocolic artery, two cases with absence of a true classical ileocolic vein, and one case of precocious bifurcation of the ileocolic artery, left to the superior mesenteric vein. The entire D3 area in all the cases was thoroughly documented and analysed from the morphometric point of view (calibres, lengths of vessels, crossing patterns). Conclusion The preoperative visualization of a patient's individual 3D anatomy is a powerful tool in identifying the variations whose negligence could have dire consequences in complete mesocolic excision of the right colon.

Background Three-dimensional (3D) printing technology has recently been well approved as an emerging technology in various fields of medical education and practice; e.g., there are numerous studies evaluating 3D printouts of solid organs. Complex surgery such as extended mesenterectomy imposes a need to analyze also the accuracy of 3D printouts of more mobile and complex structures like the diversity of vascular arborization within the central mesentery. The objective of this study was to evaluate the linear dimensional anatomy landmark differences of the superior mesenteric artery and vein between (1) 3D virtual models, (2) 3D printouts, and (3) peroperative measurements. Methods The study included 22 patients from the ongoing prospective multicenter trial “Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic MDCT Angiography,” with preoperative CT and peroperative measurements. The patients were operated in Norway between January 2016 and 2017. Their CT datasets underwent 3D volume rendering and segmentation, and the virtual 3D model produced was then exported for stereolithography 3D printing. Results Four parameters were measured: distance between the origins of the ileocolic and the middle colic artery, distance between the termination of the gastrocolic trunk and the ileocolic vein, and the calibers of the middle colic and ileocolic arteries. The inter-arterial distance has proven a strong correlation between all the three modalities implied (Pearson's coefficient 0.968, 0.956, 0.779, respectively), while inter-venous distances showed a weak correlation between peroperative measurements and both virtual and physical models. Conclusion This study showed acceptable dimensional inter-arterial correlations between 3D printed models, 3D virtual models and authentic soft tissue anatomy of the central mesenteric vessels, and weaker inter-venous correlations between all the models, reflecting the highly variable nature of veins in situ.

Background/Aims: Wireless motility capsule (WMC) detects the ileocolic junction (ICJ) in most non-operated patients. We find no data concerning this examination in patients where the ileocolic valve is replaced by a per definition incompetent, surgically created ICJ. We wanted to see if WMC could detect the ICJ after a right colectomy and assess the competency. Methods: Prospective cohort study using a within-subject design to eliminate subject-subject variability. Selected patients operated with right colectomy underwent 3 WMC examinations (pre-operatively, 3 weeks, and 6 months after surgery). Results: Twenty patients (8 men) included, 7 (4 men) excluded due to poor recordings (4) and unforeseen events (3). Thirteen patients (4 men), median age 63 years completed 3 tests. Median bowel lengths removed were 11 cm for ileum and 21 cm for colon. Thirty-nine examinations analyzed by 2 physicians who found all 13 ICJs at 3 examinations with high inter-rater reliability (intra-class correlation coefficient: 0.99, 0.91, and 0.99 respectively), whereas the computer found 9, 8, and 10 out of the 13 ICJs, respectively. Computed values significantly more often deviated from the 2 raters. Mean magnitude and duration of pH-drop at the ICJ (3 examinations) was 1.16–1.02–1.13 pH units and 3.15–4.78–3.75 minutes, respectively. pH-drop was smaller and duration longer at 3 weeks. We found no differences between the pre-operative (competent ICJ) and post-operative 6-month examinations (incompetent ICJ). Highest pressure immediately prior to ICJ was equal before and after surgery. Conclusion: WMC can identify the non-physiological ICJ after right colectomy. Ileocolic competence cannot be assessed.

Background Surgical resection is the only curative option in patients with pancreatic ductal adenocarcinoma. Little is known about the oncologic outcomes of laparoscopic distal pancreatectomy. This bi-institutional study aimed to examine the long-term oncologic results of standard laparoscopic distal pancreatectomy in a large cohort of patients with pancreatic ductal adenocarcinoma. Methods From January 2002 to March 2016, 207 patients underwent standard laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma at Oslo University Hospital-Rikshospitalet (Oslo, Norway) and Asan Medical Centre (Seoul, Republic of Korea). After the exclusion criteria were applied (distant metastases at operation, conversion to an open operation, loss to follow-up), 186 patients were eligible for the analysis. Perioperative and oncologic variables were analyzed for association with recurrence and survival. Results Median overall and recurrence-free survivals were 32 and 16 months, while 5-year overall and recurrence-free survival rates were estimated to be 38.2% and 35.9%, respectively. Ninety-six (52%) patients developed recurrence: 56 (30%) extrapancreatic, 27 (15%) locoregional, and 13 (7%) combined locoregional and extrapancreatic. Thirty-seven (19.9%) patients had early recurrence (within 6 months of operation). In the multivariable analysis, tumor size >3 cm and no adjuvant chemotherapy were associated with early recurrence ( P = .017 and P = .015, respectively). The Cox regression model showed that tumor size >3 cm and lymphovascular invasion were independent predictors of decreased recurrence-free and overall survival. Conclusion Standard laparoscopic distal pancreatectomy is associated with satisfactory long-term oncologic outcomes in patients with pancreatic ductal adenocarcinoma. Several risk factors, such as tumor size >3 cm, no adjuvant chemotherapy, and lymphovascular invasion, are linked to poor prognosis after standard laparoscopic distal pancreatectomy.

Aim Vascular abnormalities present advantages and/or disadvantages for the patient undergoing surgery. The aims of this study were to define, classify and demonstrate the courses, and to assess the clinical value, of arterial and venous abnormalities in the central mesentery. Method We conducted a review of the anatomy of 340 patients planned for enrolment in the 'Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic MDCT Angiography' trial, 312 of whom were submitted to surgery. Vascular abnormalities were analysed in context with surgical notes and images. A meta-analysis of the literature was performed. Results Arterial Abnormalities were found in 28 (8.2%) of the 340 patients and were classified into the following three groups based on anticipated surgical difficulty: group 1, accessory or replaced arteries to solid organs [14 (4.1%)]; group 2, arterial shunts [11 (3.2%)] between the coeliac trunk and the superior mesenteric artery, which resulted in bleeding in three patients; and group 3, common stem abnormalities [3 (0.9%)]. Two groups of superior mesenteric vein abnormalities were noted. The first included morphological abnormalities in a single vein [4 (1.2%)]: aneurysm [1 (0.3%)]; and ring variants of principal tributaries [3 (0.9%)]. The second included double superior mesenteric vein trunks [31 (9.1%)]: genuine bifid [10 (2.9%)]; and pseudo bifid [21 (6.2%)]. The meta-analysis revealed 26 articles, including 10 series of anatomical dissections or angiographies [1970 cases with 205 (10.4%) arterial abnormalities] and 16 case reports, none of which described a clinical or surgical setting. Conclusion Vascular abnormalities occur frequently. Arterial abnormalities are a hazard when inadvertent injury occurs during surgery. Preoperative knowledge of a bifid superior mesenteric vein is useful.

Background The outcomes following laparoscopic distal pancreatectomy (LDP) in elderly patients have not been widely reported to date. This study aimed to analyze perioperative and oncologic outcomes in patients aged ≥70 years (elderly group) and compare with those Methods From April 1997 to September 2015, 402 consecutive patients with lesions in the body and tail of the pancreas underwent LDP at Rikshospitalet, Oslo University Hospital. Results Of these, 118 (29.4%) were elderly, whereas 284 (70.6%) were non-elderly. Despite higher rate of comorbidities and American Society of Anesthesiologists score (P = 0.001 and 0.001, respectively), elderly patients had lower postoperative morbidity, pancreatic fistula (PF) and readmission rates, compared with non-elderly (P = 0.032, 0.001 and 0.025, respectively). Spleen-preserving LDP (SPLDP) resulted in similar postoperative outcomes in the two groups. Elderly patients with pancreatic ductal adenocarcinoma (PDAC) were comparable to non-elderly in terms of median and 3-year survival (20.2 vs. 19 months (P = 0.94, log-rank) and 26.7% vs. 34.3%, respectively). Conclusions Both LDP and SPLDP are safe in patients aged ≥70 years, providing outcomes similar to those in younger group. Elderly patients with PDAC can benefit from LDP, since age itself is not associated with decreased survival after surgery.

The salivary glands and pancreas have comparable anatomic and antigenic properties and can share common pathogenetic mechanisms involving toxic or autoimmune processes. The aim of this study is to assess the correlation in size between the normal submandibular glands and the pancreas. The study was based on human autopsy specimens of the pancreas, neck and oral base from 22 adults, both sexes (mean age, 57.9 years). The pancreatic and submandibular ducts were injected with a contrast medium, and the area of the salivary and pancreatic glandular ductograms was measured with the aid of software for quantification of visual information. Samples of tissue from the salivary glands and the pancreas were studied by means of light microscopy. A high correlation was found between the planimetric size of the pancreas and the submandibular glands (correlation coefficient 0.497 and 0.699 for the right and the left gland, respectively). This ratio was close to 5:1. There were no significant differences in size for the left vs. right submandibular gland (p = 0.39). The ductograms were significantly larger in size in males than in females (p lt 0.001). This study has proven a positive correlation in planimetric size between the normal submandibular glands and pancreas, a result that is expected to have possible clinical implications in the long-term follow-up of patients with chronic pancreatitis.

Background Obesity is known as a risk factor for intra- and postoperative complications in pancreatic operation. However, the operative outcomes in obese patients undergoing laparoscopic distal pancreatectomy remain unclear. Methods A total number of 423 patients underwent laparoscopic distal pancreatectomy at Oslo University Hospital-Rikshospitalet from April 1997 to December 2015. Patients were categorized into 3 groups based on the body mass index: normal weight (18.5–24.9 kg/m 2 ), overweight (25–29.9 kg/m 2 ), and obese (≥30 kg/m 2 ). After excluding underweight patients, 402 patients were enrolled in this study. Results Obese patients had significantly longer operative time and increased blood loss compared with overweight and normal weight patients (190 [61–480] minutes vs 158 [56–520] minutes vs 153 [29–374] minutes, P = .009 and 200 [0–2,800] mL vs 50 [0–6250] mL vs 90 [0–2,000] mL, P = .01, respectively). A multiple linear regression analysis identified obesity as predictive of prolonged operative time and increased blood loss during laparoscopic distal pancreatectomy. The rates of clinically relevant pancreatic fistula and severe complications (≥grade III by Accordion classification) were comparable in the 3 groups ( P = .23 and P = .37, respectively). A multivariate logistic regression model did not demonstrate an association between obesity and postoperative morbidity ( P = .09). The duration of hospital stay was comparable in the 3 groups ( P = .13). Conclusion In spite of longer operative time and greater blood loss, laparoscopic distal pancreatectomy in obese patients is associated with satisfactory postoperative outcomes, similar to those in normal weight and overweight patients. Hence, laparoscopic distal pancreatectomy should be equally considered both in obese and nonobese patients.

In the era of competency-based surgical education, VBC has gained increased attention and may enhance the efficacy of surgical education. The objective of this systematic review was to summarize the existing evidence of video-based coaching (VBC) and compare VBC to traditional master-apprentice-based surgical education. We performed a systematic review and meta-analysis of randomized controlled trials (RCT) assessing VBC according to the PRISMA and Cochrane guidelines. The MEDLINE, EMBASE, and COCHRANE and Researchgate databases were searched for eligible manuscripts. Standard mean difference (SMD) of performance scoring scales was used to assess the effect of VBC versus traditional training without VBC (control). Of 627 studies identified, 24 RCTs were eligible and evaluated. The studies included 778 surgical trainees (n = 386 VBC vs. n = 392 control). 13 performance scoring scales were used to assess technical competence; OSATS-GRS was the most common (n = 15). VBC was provided preoperative (n = 11), intraoperative (n = 1), postoperative (n = 10), and perioperative (n = 2). The majority of studies were unstructured, where identified coaching frameworks were PRACTICE (n = 1), GROW (n = 2) and Wisconsin Coaching Framework (n = 1). There was an effect on performance scoring scales in favor of VBC coaching (SMD 0.87, p

Background 3D vascular anatomy roadmaps are currently being implemented for surgical planning and navigation. Quality of the reconstruction is critical. The aim of this article is to compare anatomical completeness of models produced by manual and semi-automatic segmentation. Methods CT-datasets from patients included in an ongoing trial, underwent 3D vascular reconstruction applying two different segmentation methods. This produced manually-segmented models (MSMs) and semi-automatically segmented models (SAMs) which underwent a paired comparison. Datasets were delivered for reconstruction in 4 batches of 6, of which only batch 4 contained patients with abnormal anatomy. Model completeness was assessed quantitatively using alignment and distance error indexes and qualitatively with systematic inspection. MSMs were the gold standard. Assessed vessels were those of interest to the surgeon performing D3-right colectomy. Results 24 CT-datasets (13 females, age 44–77) were used in a paired comparative analysis of 48 3D-models. Quantitatively, SAMs showed structural improvement from Batch 1 to 3. Batch 4, with abnormal vessels, showed the highest error-index values. Qualitatively, 91.7% of SAMs did not contain all mesenteric branches relevant to the surgeon. In SAMs, 1 (12.5%) right colic artery-RCA scored as a complete vessel. 3 (37.5%) RCAs scored as incomplete and 4 (50%) RCAs were absent. 6 (25%) of 24 middle colic arteries-MCA scored as complete vessels. 11 (45.8%) scored as incomplete while 7 (29.2%) MCAs were absent. 13 (54.2%) of 24 ileocolic arteries-ICA were complete vessels. 11 (45.8%) scored as incomplete. None (0%) were absent. Additionally, it was observed that 10 (41.7%) of SAMs contained all their jejunal arteries, when compared to MSMs. Calibers of “complete” vessels were significantly higher than in “missing” vessels (MCA p < 0.001, RCA p = 0.016, ICA p < 0.001, JAs p < 0.001). Conclusion Despite acceptable results from quantitative analysis, qualitative comparison indicates that semi-automatically generated 3D-models of the central mesenteric vasculature could cause considerable confusion at surgery.

Background Surgical techniques like complete mesocolic excision (CME) and D3 mesenterectomy, D3 refering to the N3 lymph node groups central in the mesentery removed at surgery, were introduced without proper evaluation of the lymphadenectomy. The aim of this study was to measure the vascular stumps and evaluate the extent and quality of lymphadenectomy after right colectomy with extended D3 mesenterectomy anterior/posterior to the mesenteric vessels. We also compared the investigation methods. Methods Residual vascular stumps were measured using three-dimensional (3D) reconstructed anatomy from follow-up computed tomography (CT) datasets and images taken during surgery. The quality of central lymphadenectomy was evaluated on the images. Results In total, 31 patients (15 females), median age 67 years (50–78), with stage I (n=7), stage II (n= 13), and stage III (n= 11) disease, were operated. Tumor locations were: 14 (45%) in the cecum, ten (32%) in the ascending colon, three (10%) in the hepatic flexure, and four (13%) in the transverse colon. The middle colic artery (MCA) was divided at its origin (13 patients) or its right branch (18 patients). Median lengths (range) of residual vascular stumps measured on 3D reconstructed CT and photographic images taken during surgery were: right colic artery: 0.0 mm (0.0–1.8)/0.0 mm (0.0–1.1), ileocolic artery: 0.0 mm (0.0–7.2)/0.0 mm (0.0–3.0), ileocolic vein: 0.0 mm (0.0–7.5)/0.0 mm (0.0–0.0), MCA: 0.0 mm (0.0–18.1)/1.0 mm (0.0–8.0), and right branch of the MCA: 0.0 mm (0.0–1.8)/0.0 mm (0.0–2.0). There was no significant difference between average lengths measured with the two techniques. The extent of lymphadenectomy was deemed acceptable in all patients. No differences in stump lengths were found in patients with different vascular crossing patterns in the central mesentery and presumably different degree of difficulty at surgery. Conclusion The results demonstrate very short residual vascular stumps and together with operative photographs provide objective evidence for superior lymphadenectomy in right colectomy with extended D3 mesenterectomy.

BACKGROUND: In right colectomy for cancer, complete mesocolic excision and D3 lymphadenectomy each leave behind lymphatic tissue anterior and posterior to the superior mesenteric vein (SMV) and artery (SMA). In this article, we present D3 extended mesenterectomy: a surgical technique that excises the lymphatic tissue en bloc with the right colectomy specimen. MATERIAL AND METHODS: A 3D map of the mesentery of the right colon was reconstructed from staging CT-angiogram scans. The surgical technique of right colectomy with D3 extended mesenterectomy consisted of eight steps: 1) reveal the SMV and SMA; 2) isolate the ileocolic artery; 3) isolate the middle colic artery; 4) resolve the anterior mesenteric flap; 5) specimen de-vascularization; 6) colectomy; 7) resolve the posterior mesenteric flap; and 8) anastomosis. RESULTS: One-hundred-seventy-six patients (77 men) 66 years of age were operated upon from February 2011 to January 2017. There were 169 adenocarcinomas: 16.0% Stage I, 49.1% Stage II, 33.7% Stage III, 1.2% Stage IV. Tumor locations were 50.6% cecum, 41.5% ascending colon, 4.5% hepatic flexure, and 2.3% transverse colon. Mean operating time was 200 minutes, blood loss 273 ml, and length of stay 7.9 days. There were 9 anastomotic leakages and 15 reoperations. One patient underwent small bowel resection due to SMA tear. There was no postoperative mortality. The mean number of lymph nodes per specimen (40.9) was comprised of 27.1 in the D2 volume and 13.8 in the D3 volume. The mean number of metastatic lymph nodes was 1.2 in the D2 volume and 0.13 in D3. There were 7 patients with lymph node metastasis in D3, 2 of whom had node metastasis solely within D3. CONCLUSION: This study shows that 1.2% of patients would have been incorrectly diagnosed as Stage II if extended D3 mesenterectomy had not been performed. Similarly, lymph node metastases would have been left behind in 4.1% of patients if extended D3 mesenterectomy had not been performed.

Previous studies report successful application of laparoscopic pancreatic enucleation (LPE). However, the evidence is limited to small series. This study aimed to evaluate the indications, technique and outcome of LPE at a tertiary care institution. Between February 1998 and April 2016, 45 consecutive LPEs were performed at Oslo University Hospital—Rikshospitalet. Twenty-four (53.3 %) patients subjected to right-sided LPE (RLPE) were compared with 21 (46.7 %) patients who had undergone left-sided LPE (LLPE). A case-matched analysis (1:2) was performed to compare the outcomes following LLPE and laparoscopic distal pancreatectomy (LDP). Patient demographics, BMI, ASA score and pathological characteristics were similar between the RLPE and LLPE groups. Operative time was slightly longer for RLPE [123 (53–320) vs 102 (50–373) min, P = 0.09]. The rates of severe morbidity (≥Accordion grade III) and clinically relevant pancreatic fistula (grades B/C) were comparable, although with a trend for higher rate of complications following LLPE (16.7 vs 33.3 %; P = 0.19 and 20.8 vs 33.3 %, P = 0.34, respectively). The hospital stay was similar between RLPE and LLPE [5 (2–80) vs 7 (2–52), P = 0.49]. A case-matched analysis demonstrated shorter operating time [145 (90–350) vs 103 (50–233) min, P = 0.02], but higher readmission rate following LLPE (25 vs 3.1 %, P = 0.037). LLPE seems to be associated with a higher risk of postoperative morbidity and readmission rates than LDP. RLPE is a feasible, safe approach and a reasonable alternative to pancreatoduodenectomy in selected patients with pancreatic lesions.

Extended resection is required for pancreatic adenocarcinoma infiltrating adjacent organs and structures. The role of laparoscopy in this setting is unclear. In this study, the outcomes of extended laparoscopic distal pancreatectomy (ELDP) for pancreatic body/tail adenocarcinoma were examined. Perioperative and oncologic data were analyzed in patients undergoing laparoscopic distal pancreatectomy (LDP) for adenocarcinoma at Oslo University Hospital. ELDP was defined as suggested by the International Study Group for Pancreatic Surgery. The outcomes of ELDP were compared to those following standard LDP (SLDP). From August 2001 to June 2016, 460 consecutive patients underwent LDP for pancreatic neoplasms including 116 (25%) adenocarcinoma. SLDP and ELDP were applied in 78 and 31 patients, respectively. The adrenal gland (33%) and colon (21%) were the most frequently resected organs during ELDP. The latter was associated with larger tumor size (5.5 vs 4 cm, p = 0.03), longer operative time (236 vs 158 min, p = 0.001) and higher conversion rate (16 vs 3%, p = 0.019) compared with SLDP. Morbidity and 90-day mortality were similar. Median follow-up was 18 months. In patients with ductal adenocarcinoma, ELDP (n = 22) was associated with significantly shorter recurrence-free and overall survival than SLDP (n = 59) (6.2 vs 9.6 months, p = 0.047 and 12.9 vs 27 months, p

D3 extended mesenterectomy (D3EM) for right colon cancer has received increased attention owing to suggested improvement of oncological outcomes. The aim of this study was to evaluate the proficiency-based progression of content-valid metrics in a cadaveric model for right colectomy with D3EM.Three expert surgeons were enrolled. Surgeon one performed the procedure robotically and surgeons two and three performed open D3EM. Proficiency-based progression was recorded for eight content-valid outcomes. The superior mesenteric vein (SMV) and artery were cannulated by independent observers to evaluate vascular tears. The specimens were analyzed for lymph node harvest by a pathologist blinded to surgical access and to the surgeon.Operating times did not differ among surgeons (50.2, 32.4 and 43.7 min). SMV tears occurred in procedures A and B only. There was no significant progression in lymph node harvest for D2 (p=0.913) and D3EM (p=0.264).Cadaveric training in D3EM was associated with progression in avoidance of vascular tears with no significant changes in operating time and lymph node harvest.

Three-dimensional (3D) printing technology has recently been well approved as an emerging technology in various fields of medical education and practice; e.g., there are numerous studies evaluating 3D printouts of solid organs. Complex surgery such as extended mesenterectomy imposes a need to analyze also the accuracy of 3D printouts of more mobile and complex structures like the diversity of vascular arborization within the central mesentery. The objective of this study was to evaluate the linear dimensional anatomy landmark differences of the superior mesenteric artery and vein between (1) 3D virtual models, (2) 3D printouts, and (3) peroperative measurements.The study included 22 patients from the ongoing prospective multicenter trial "Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic MDCT Angiography," with preoperative CT and peroperative measurements. The patients were operated in Norway between January 2016 and 2017. Their CT datasets underwent 3D volume rendering and segmentation, and the virtual 3D model produced was then exported for stereolithography 3D printing.Four parameters were measured: distance between the origins of the ileocolic and the middle colic artery, distance between the termination of the gastrocolic trunk and the ileocolic vein, and the calibers of the middle colic and ileocolic arteries. The inter-arterial distance has proven a strong correlation between all the three modalities implied (Pearson's coefficient 0.968, 0.956, 0.779, respectively), while inter-venous distances showed a weak correlation between peroperative measurements and both virtual and physical models.This study showed acceptable dimensional inter-arterial correlations between 3D printed models, 3D virtual models and authentic soft tissue anatomy of the central mesenteric vessels, and weaker inter-venous correlations between all the models, reflecting the highly variable nature of veins in situ.

Aims: The treatment of gastric cancer has changed in the western countries during the last decade. This includes multidisciplinary team (MDT) meetings, perioperative chemotherapy, extended lymph node dissection, and laparoscopic surgery, all of which were gradually implemented at our department from 2008. The aim of the present study was to determine the effect of these changes on morbidity and survival. Material and Methods: 185 patients with gastric cancer were operated with curative intent from 2000 until 2016 in this retrospective, observational, follow-up study; 83 before implementation of modern principles in 2008 (period 1) and 102 were treated after 2008 (period 2). Results: The resection rate (94% vs 92.8%) and mortality rates (4.8% vs 2.9%) did not differ between the two periods. In period 2, 48 patients (47.1%), received neoadjuvant chemotherapy. In 36 patients (35.3%), laparoscopic surgery with D2 lymphadenectomy was performed. There was a significantly higher yield in the number of lymph nodes in period 2 compared to period 1 (14 vs 8, p < 0.001). This is also apparent between laparoscopic and open surgery in the second period (32 vs 10, p < 0.001). The five-year survival rate was significantly improved after the change in treatment principles with an estimated improvement from 30% to 40% between the periods (p = 0.033). Conclusion: The combined effect of MDT meetings, neoadjuvant chemotherapy, extended lymphnode dissection and laparoscopy has improved the prognosis of gastric cancer patients. KEYWORDS Gastric Cancer, Chemotherapy, Laparoscopy, Survival, D2 Lymphadenectomy

Dear Editor, I would like to congratulate the authors of this well written article and to thank them for the contribution to the literature. There is, however, one point that needs to be addressed, and that is the outcomes of surgical versus conservative treatment. Areview article1 has published data on 266 patients (106 patients derived from published case reports containing individual patient data, 113 patients derived from the Norwegian patient registry and data on 47 patients as historical controls from a previous publication and used as historical controls(Chendrasekhar et al2). It seems that conservatively treated patients had similar hospital length of stay as operated patients. Age did correlate with hospital stay, howeverno difference in outcomes for operated or non-operated patients was found. The historical control group did show a significantly higher mortality, implying that attempting conservative therapy after diagnosis through an abdominal CT scan (which often does show pneumoperitoneum) can only benefit this frail patient group.

Background The middle colic artery (MCA) is of crucial importance in abdominal surgery, for laparoscopic or open right and transverse colectomies. Against this background, a high number of reports concerning anatomical variations of the MCA have been published intended to contribute to the improvement of operative techniques for the treatment of colon cancer. Despite this extensive literature, briefly reviewed in the present paper, a course of the MCA posterior to the superior mesenteric vein, called a retromesenteric trajectory, has been related to only once, to the best of our knowledge. Methods A total series of 507 patients included in two prospective trials concerning laparoscopic or open right colectomy for cancer between 2011 and 2017 are reported. The investigation included preoperative or postoperative multidetector-computed tomography angiography. Results We found four (0.79%) cases of retromesenteric MCA. They all underwent meticulous image analysis with mesenteric vessels' road mapping, detailedmorphometry, and surgical validation which revealed that, apart from their course, those cases did not differ significantly from the rest of the series. Conclusion This paper therefore documents the worth-knowing behavior causing considerable confusion for the operating surgeon unaware of the abnormality and shows its concrete impact on patient-tailored surgical practice, in particular for laparoscopic D3 colectomy (including the Buncinated process first^ approach).

Background: Laparoscopic D3 anterior posterior extended mesenterectomy (D3APEM) in right colectomy has received increased attention. The aim of this study is to prove feasibility, systemize technical accomplishment, and provide short-term outcomes data. Methods: From July 2013 to February 2017, 18 patients with adenocarcinoma in the right colon underwent right colectomy with laparoscopic D3APEM, including lymph nodes anterior and posterior to the superior mesenteric vessels. A reconstructed three-dimensional anatomy map derived from the staging computed tomography was used as a road map at surgery. The procedure was systematized into seven operative steps: Step 1, trocar placement and inspection; Step 2, release of the transverse colon; Step 3, identification of the terminal mesenteric vessels; Step 4, release of the anterior flap; Step 5, division of the transverse mesocolon; Step 6, release of the posterior flap; and Step 7, anastomosis and specimen removal. Patient disposition and variations regarding vascular anatomy and ability to expose consequentially may necessitate a variation in the sequence of the steps. Results: A total of 7 (39%) cases were converted, 3 due to bleeding and 4 due to challenging dissection. Median operative time and blood loss were 276 minutes (168–439 minutes) and 200 mL (